A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
Post a detailed written schedule of daily activities.
Use an overhead loudspeaker to announce events.
Allow the client to choose free-time activities.
Provide a consistent daily routine.
The Correct Answer is D
A. Post a detailed written schedule of daily activities: Clients with Alzheimer’s often have impaired memory and comprehension, so a detailed written schedule may be confusing or overwhelming rather than helpful.
B. Use an overhead loudspeaker to announce events: Loud or unexpected noises can increase agitation or confusion in clients with dementia. Overhead announcements are not calming and should be avoided.
C. Allow the client to choose free-time activities: While promoting autonomy is important, clients with Alzheimer’s may struggle with decision-making. Too many choices can lead to frustration or anxiety.
D. Provide a consistent daily routine: Predictability and routine help reduce confusion, anxiety, and agitation in clients with Alzheimer’s. A structured environment supports cognitive function and emotional well-being.
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Related Questions
Correct Answer is A
Explanation
A. This client may be developing compartment syndrome, a medical emergency characterized by increased pressure within a confined space, which can lead to permanent nerve and muscle damage. Immediate assessment is essential to prevent ischemia or tissue loss.
B. Discharge planning can be addressed after higher-priority needs are met. This client is stable and not showing signs of acute complications, making this a non-urgent concern compared to a potential compartment syndrome.
C. While assisting with meals supports client comfort and nutrition, it is a routine task. This client is not experiencing an emergent issue and can safely wait until more urgent needs are addressed.
D. Not all client needs carry the same urgency. Prioritization is essential in nursing care, especially when one client exhibits signs of a possible limb-threatening complication such as compartment syndrome.
Correct Answer is A
Explanation
A. Deviation of a great toe laterally: Hallux valgus, commonly known as a bunion, is characterized by the lateral deviation of the great toe toward the other toes. This deformity often leads to pain, swelling, and difficulty with footwear due to joint misalignment.
B. Abnormal flexion of the great toe: Abnormal flexion is more consistent with hammer toe or claw toe deformities. It does not describe the lateral displacement seen in hallux valgus.
C. An exaggerated arch of the foot: An exaggerated arch, or pes cavus, is a separate structural foot abnormality and is not associated with hallux valgus. It involves the shape of the foot, not the alignment of the toe.
D. Fusion of the toe joints: Fusion of toe joints may occur due to arthritis or surgical intervention but is not a typical feature of hallux valgus. Hallux valgus involves joint misalignment rather than joint fusion.
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